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Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Dec*, Shed,
RspaidReplace. Olher
PLEASE FILL OUT LEOIBLY A COMPLETELY TO AVOID DELAYS IN PROCE=W
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build accor&V.to the fdbwing
Owner's Name i 4-\Ae�l nuj go_, 1) /1 v 7-214L:
Address & Phone G fe j aeon fiyt •
Architect's Name
Address d Phone \ ( ( 1
Mechanics Name
Address & Phone I
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Signature of Applicant
$IGNED UNDER THE PENALTY.
OR PERWRY
OF WORK,TO BE GONE
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MAIL PERMIT TO:
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CITY OF SALEM
BUIIDING DEPARTMENT
HOMEOWNERUCENSEE MOMON
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APPROVAL OF BUIIDING VVECTOR
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HOMEOWNER'S EXEMPTION
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CITY OF SALEMV MASSACHUSETTS
PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET, 3RD FLOOR
SALEM, MA O 1970
TEL. (978)745-9595 EXT. 380
04& FAX (978) 740-9846
STANLEY J. USOVICZ, JR.
MAYOR
DISPOSAL OF DEBRIS AFFIDAVIT
In accordance with the provisions of MGL c 40, S34, I acknowledge that as a condition
of Building Permit# ,all debris resulting from the construction activity
governed by this Building Permit shall be disposed of in a properly licensed solid-waste
disposal facility,as defined by MGL c III,S150A.
The debris will be disposed of at:
Location of Facility
SignatuA of Permit 1101
10 'cant DAe
FULLY complete the following information:
(PLEASE PRINT CLE�A^RLY) l
tYn�e, g_4 I �'Iic�,z�� JJI �uzz�—
Name of Permit Applicant
Firm Name,if any CC
�'PF:VI �CUti✓1 � �2'��l
Address,City& State
The above statute requires that debris from the demolition, renovation, rehab or other
alteration of building or structure be disposed in a properly-licensed solid-waste disposal
facility as defined by MGL cIII, S 150A, and the building permits or licenses are to
indicate the location of the facility.
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SURVEY PLAN OF LAND
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SA L E N/1 ' MASS,
PREPARED BY:
'a?} PJ.F. & ASSOCIATES
11 9_EASON ST. MEDFORD. M,1
a tic PAUL J. F NIOC-C O—P.LS.
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DEED REF I
BA TEI
FILE No.l
PAUL J. FINOCCHID P.L.S, DATEI ? 2�